Belliard H, Roux F X, Turak B, Nataf F, Devaux B, Cioloca C
Service de Neurochirurgie, Centre Hospitalier Sainte Anne, Paris.
Neurochirurgie. 1996;42(3):139-45; discussion 145-6.
Fifty three Codman Medos programmable valves were implanted in 50 patients (28 men and 22 women) aged 5 to 77 years, from April 1992 to February 1994. They presented with a hydrocephalus 43 times, an arachnoid cyst three times and a CSF leakage four times. The aims of this study were: a) to test the reliability of this equipment, in current use as well as its eventual advantages, inconveniences and restraints, b) to determine its best indications. Follow-up ranged from 12 to 36 months (average = 22 months). Five patients were lost for follow-up. One patient died from a post-operative sepsis. Four died from their disease. Infectious complications concerned 6 patients (11%). A radio-clinical overdrainage syndrome appeared in 9 patients with slit-ventricles, 5 of them associated with sub-dural collections. All these cases were treated with shunt reprogrammings. While 43 pressure settings over 53 were satisfactory in the immediate post-operative period, it appeared that only 38% of shunts had required one only setting when the study period was over. A certain number of pressure adjustments malfunctioned: 6 times, post-operative X-ray controls showed pressures significantly different from the figures which had been selected (difference from -30 mm H2O to + 70 mm H2O); pressure readjustments were effective and accurate for five of them, but one shunt had to be changed; 15 deprogrammings were detected during long term follow-up, 9 of them after MR1. Pressure programming was readjusted only on patients presenting with clinical signs, i-e mainly for those having a pressure difference > +/-30 mm H2O. As a conclusion, the authors consider that such a shunt can be very useful in some precise indications as: NPH, multioperated hydrocephalus, arachnoid and porencephalic cysts, some spontaneous or iatrogenic CSF leakages, temporary shunts necessitating a progressive withdrawal. Because of a) the cost of this equipment, b) the specific restraints (X-rays controls, programmer), and c) the specific incidents (spontaneous and/or post-MR1 deprogramming), it seems difficult to generalize indications to all cases of hydrocephalus. On the other hand, these shunts have the great advantage of simplifying the treatment of overdrainage by avoiding, in all cases, a reoperation for changing the shunt and/or removing a subdural hematoma. Consequent economies due to a significant diminution of the duration of hospitalisation, could justify an enlargement of indications.
1992年4月至1994年2月，50例年龄在5至77岁的患者（28例男性和22例女性）植入了53个Codman Medos可编程阀门。其中43例为脑积水，3例为蛛网膜囊肿，4例为脑脊液漏。本研究的目的是：a）测试该设备在当前使用中的可靠性及其潜在的优点、不便之处和限制；b）确定其最佳适应证。随访时间为12至36个月（平均22个月）。5例患者失访。1例患者死于术后败血症。4例死于疾病。6例患者（11%）出现感染并发症。9例裂隙脑室患者出现放射性临床引流过度综合征，其中5例伴有硬膜下积液。所有这些病例均通过调整分流器程序进行治疗。虽然53个分流器中有43个在术后即刻压力设置令人满意，但在研究结束时，似乎只有38%的分流器只需要一次设置。一定数量的压力调整出现故障：6次术后X线检查显示压力与所选数值有显著差异（相差-30 mmH₂O至+70 mmH₂O）；其中5次压力重新调整有效且准确，但有1个分流器必须更换；在长期随访中检测到15次程序重置，其中9次在磁共振成像（MRI）后。仅对出现临床症状的患者，即主要是压力差>±30 mmH₂O的患者进行压力程序重新调整。作为结论，作者认为这种分流器在某些特定适应证中非常有用，如正常压力脑积水、多次手术的脑积水、蛛网膜囊肿和脑穿通畸形囊肿、一些自发性或医源性脑脊液漏、需要逐步撤除的临时分流器。由于a）该设备的成本，b）特定的限制（X线检查、编程器），以及c）特定的事件（自发性和/或MRI后的程序重置），似乎难以将适应证推广到所有脑积水病例。另一方面，这些分流器具有很大的优势，即通过在所有情况下避免再次手术更换分流器和/或清除硬膜下血肿来简化引流过度的治疗。由于住院时间显著缩短而带来的相应经济效益，可能证明扩大适应证是合理的。
